The Aorta…The Clinical Chameleon.

Angie Carrick, DO, FACOEP, FACEPAPD Norman Regional EM Residency

Co-Director Stroke Program

No disclosures. I just like to teach!

1. Confront the diagnostic challenge that is Aortic Dissection.

2. Identify key historical points that should raise your suspicion for dissection.

3. Discuss essential exam components in your patients with probable dissection.

4. Examine important risk factors to ask these patients.

Objectives

“There is no disease more conducive to clinical humility than aneurysm of the aorta.”

—Sir William Osler, 1900

15-43%

Classic Triad in only 1/4

4/100,000

Lesson #1The History

"Listen to your patient, he is telling you the diagnosis.”

—Sir William Osler

41 yo FCC: CP, confused

PMH: HTN, GERDVS: T 36.7 P 107 BP

140/90 RR 14, Sat 99%

Notes: onset 10 min. PTACP: severe, rad to neck

L arm numb“using words inapp.not making sense”

Case 1: The History

case 2

• ekg

• cxr

CT Head: No acute changes

• CT head pic= neg.

• CTA pic=dissection

CTA: appears to be a dissection flap in the aorta extending to the great vessels. Impression: Findings concerning for ascending thoracic dissection.

CTA: ascending aorta dilated up to 5.2 cm. Impression: Stanford Type A dissection from proximal thoracic aorta to the great vessels.

41 yo FCC: CP, confused

PMH: HTN, GERDVS: T 36.7 P 107 BP

140/90 RR 14, Sat 99%

Notes: onset 10 min. PTACP: severe, rad to neck

L arm numb“using words inapp.not making sense”

CP + neuro deficit = LR 33

5% present as CVA

“CP + 1” Concept

CP + CVA

CP + Paralysis

CP + Limb ischemia

CP + Syncope

Lesson #2: The Exam

73 yo MCC: CP PMH: HTN

VS: T 98 P 62 BP 98/38 RR 16, Sat 97%

Notes: acute pain sitting @ breakfast 90 min. PTA

near syncopeEMS: confusedbradycardia 40sgiven atropine

Case 2

Case 2

Case 2

Case 2

Case 2

• Bedside

• Unstable patients

• Rapid Diagnosis

POCUS

R shoulder

POCUS

3

4

3. PSL• Flap• Dilated

arch1

2

3. Abd Aorta: Dilation & Flap

1. Subxiphoid • Pericardial

effusion

4. Suprasternal • Dilated arch

ACEP Policy Statement

• Level C: “In adult patients with suspected dissection, immediate surgical consultation or transfer to a higher level of care should be considered if a TTE is suggestive of aortic dissection.”

Additional exam findings

Acute AR 30%+LR=5

+LR=2.7

15%

Marfan’s

Lesson #3: Risk Factors

Case 3 DS

Case 3 DS

30’s yo MCC: CP PMH: HTN

VS: T 98 P 128 BP 153/98 RR 26, Sat 96%

Notes: Sharp/stab substernal rad to neck

L arm tingling after intercourse

• Marfan’s

• Bicuspid Aortic Valve

• Turner Syndrome

• Inflammatory Diseases

• Pregnancy

• Aortic instrumentation/surgery

• FH of aneurysm

“WALL WEAKENERS”

•HTN 72%

2.5X ⬆ Risk

1.66X ⬆ Risk

2.14X ⬆ Risk

Catecholamine Surge ➟

Abrupt increase in BP• Heavy weight lifting

• Sexual intercourse

• Energy drinks

• Cocaine

• “shoveling show”

• “doing push-ups”

• “bad business lunch”

• “big losses at casino”

• “hard cough”

.Thorac CV Surg 2016

270 patients age <60

Intercourse6%

Rest8%

Unknown24% Exertion

62%

16% age <5011% age <60

0% ♀

Abrupt85%

Worst91%

Evaluation History/Risk Factors

Examination: Pulses, Murmur, Neuro

POCUS

Labs

EKG

CXR

• Troponin ⬆ 25%• ACEP Clinical Policy on D-dimer

“…do not rely on D-dimer alone to exclude the diagnosis”

%

Non Spec Normal Ischemic AMI

515

3041

EKG findings in Aortic Dissection

EKG findings in Aortic Dissection

AMI 1000X more common than AD

What do you do?

Wide MediastinumTrachea Deviation

Abnormal Aortic Knob

60%

Calcium SignDouble Density

Management

Call Surgeon

Pain Control

Heart Rate Control

Blood Pressure Control

• Pulse

Goal 60 bpmEsmololLabetalol

DiltiazemVerapamil

• Pulse

Goal SBP 110NicardipineClevidipineNitroprusside

180/110 140/85

Summary1. Aortic dissection is time sensitive.2. AD can masquerade itself.3. Consider this in Chest Pain PLUS 1.4. Exam findings of new murmur, Marfan’s

signs or pulse/neuro deficits could help clinch the diagnosis.

5. Use POCUS to identify tamponade or a flap.6. Listen for history of “wall weakeners” or BP

“surgers”.

References1. Hagan MB, Peter, et al. The International Registry of Acute Aortic Dissection (IRAD) New Insights Into an Old Disease. JAMA,

February 16, 2000.

2. Rosman MD, Howard, et al. Quality of History Taking in Patients with Aortic Dissection. Chest, 114, 3, September, 1998.

3. Klompas MD, Michael. Does This Patient Have an Acute Thoracic Aortic Dissection? JAMA, May 1, 2002.

4. Muiteng, Chua MD, et al. Acute aortic dissection in the ED: risk factors and predictors for missed diagnosis. American Journal of Emergency Medicine (2012) 30, 1622–1626

5. Strayer, Reuben J, MD, et al. Screening, Evaluation, and Early Management of Acute Aortic Dissection in the ED. Current Cardiology Reviews, 2012, 8, 152-157.

6. Pare, MD, Joseph, et al. Emergency physician focused cardiac ultrasound improves diagnosis of ascending aortic dissection. American Journal of Emergency Medicine 34 (2016) 486–492.

7. Colla, J S MD, et al. Emergency Ultrasound: Identification of Aortic Dissection Using Limited Bedside Ultrasound. Emergency Medicine. 2017 March;49(3):135-137

8. Kosuge, M. MD, PhD. Clinical Implications of Electrocardiograms for Patients With Type A Acute Aortic Dissection. Circ J 2017; 81: 1254–1260.

9. https://emergencymedicinecases.com/aortic-dissection-em-cases-course/

10.http://www.emdocs.net/acute-aortic-dissection-3/

11.https://coreem.net/core/aortic-dissection/

12.https://www-uptodate-com.ezproxy.chs.okstate.edu/contents/clinical-features-and-diagnosis-of-acute-aortic-dissection?search=aortic%20dissection&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H27023034

13. https://vimeo.com/391548110 (5 minute sono of Aortic Dissection)

14. http://www.thepocusatlas.com/aorta-1

15. https://images.app.goo.gl/yBLNeb1fN5myTSh97

16. Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 73356

17. https://images.app.goo.gl/yBLNeb1fN5myTSh97

18. http://hqmeded-ecg.blogspot.com/2018/10/is-this-stemi-no-not-by-definition-why.html

19.https://www.openpediatrics.org/assets/image/rhythm-strip-normal-sinus-rhythm

Handout• Great websites for review on Aortic Dissection

1. https://youtu.be/Ivrw3M2uJFI (EM:RAP aorta US) video

2. https://vimeo.com/391548110 (5 minute sono of Aortic Dissection)

3. Esmolol drip sheet: https://emcrit.org/wp-content/uploads/2013/01/esmolol-drip-sheet.pdf

4. https://coreem.net/core/aortic-dissection/

5. https://emergencymedicinecases.com/aortic-dissection-em-cases-course/

6. http://www.emdocs.net/acute-aortic-dissection-3/

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